Incident Report Form
This form is to be completed by an adult witness whenever an incident requiring secondary medical attention
First Name
*
Last Name
*
Email Address
*
Phone Number
*
Date of Birth
*
Home Address
*
Name of Parents/Guardians
*
Name of injured person
*
Date & Time of incident
*
Describe the incident
*
Where in facility did it happen?
*
How did the incident happen?
*
What area(s) of the person's body was injured?
*
Name of the leaders supervising at the time of the incident?
*
What was the person doing when the incident happened? E.g ministry or event
*
Name of any other witnesses to the incident
*
How did the person respond after the incident?
*
Was first aid given?
*
If 'yes', by whom?
Submit